pay for performance: experiences within an integrated delivery system

Pay for Performance: Experiences Within An Integrated Delivery System

Jessica C. Dudley, M.D.

Chief Medical Officer

Brigham and Women’s Physicians Organization

[email protected]

March 4, 2009

2

Key points

P4P Contracts have begun to engage physicians around addressing quality and efficiency…but there are limitations.

The intense expansion of medical knowledge and technology are major contributors to rising costs, but provide us an incredible opportunity to diagnose and treat conditions previously unrecognized or untreatable.

The electronic medical record is a critical tool in providing physicians with the best available information about an individual patient and is key to improving efficiency and effectiveness of care.

Data and reporting are essential for measurement of performance; showing variation vs. one’s peers is an effective means to engage physicians.

Care reimbursement models continue to evolve, and alternative payment models which support (and reward) quality and efficiency of care delivery will need to be developed.

3

Agenda

Partners Healthcare System (PHS) and Brigham and Women’s Physicians Organization (BWPO)

Pay for performance (P4P)– Medical management and P4P at PHS and BWPO

Efficiency: Pharmacy example Quality: Diabetes example Process: E-Prescribing example

Future– CMS PQRI and VBP– Other

4

Partners HealthCare: An Integrated Delivery System

Partners HealthCare System, Inc.

Partners HealthCare System, Inc.

Two Physicians Appointed by Partners

Two Physicians Appointed by Partners

Brigham And

Women’s/ Faulkner Hospitals

Brigham And

Women’s/ Faulkner Hospitals

Partners CommunityHealthCare,

Inc.

Partners CommunityHealthCare,

Inc.

North Shore Medical

Center, Inc.

North Shore Medical

Center, Inc.

Dana-Farber/ Partners Joint

Venture

Dana-Farber/ Partners Joint

Venture

Newton- Wellesley Hospital,

Inc.

Newton- Wellesley Hospital,

Inc.

Newton- Wellesley

Health Care System, Inc.

Newton- Wellesley

Health Care System, Inc.

The Brigham

and Women’s Hospital,

Inc.

The Brigham

and Women’s Hospital,

Inc.

The General Hospital

Corporation

The General Hospital

Corporation

The Massachusetts

General Hospital

The Massachusetts

General Hospital

Faulkner Hospital,

Inc.

Faulkner Hospital,

Inc.

Founded in 1994, shortly after the founding of Partners.

PCHI is the provider network for Partners.

Intentionally given entity status to assure MD voice and build trust

5

Eastern Massachusetts PCHI Overview

100 miles

75 miles

PHS Market Share Data:

Adult IP Admissions: 22% (1)

PCPs: 23% (2)

PHS Market Share Data:

Adult IP Admissions: 22% (1)

PCPs: 23% (2)

(1) Source: Massachusetts Division of Healthcare Finance and Policy; Ages 0-17 excluded.

(2) Sources: Folios, Partners Corporate Provider Master, PCHI

6

Network Composition

Partners Community Healthcare, Inc

~6,337 Total MDs

Primary Care: ~1,162 Specialist: ~ 5,175

Community: ~743

Academic: ~ 419

Community: ~1,879

Academic: ~3,296

PHS Community Hospital PHOs:

1,013

Integrated Practices:

233

Affiliated Groups & PHOs::

1,376

More tightly aligned

Less tightly aligned

Total: 2,622

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Components of a Clinically Integrated Network

1. Common practice standards and protocols to govern treatment.

– Uniform across the network and across contracts

– Developed and/or implemented via collaboration among MDs (PCPs and specialists).

2. Programs to monitor and control utilization and ensure quality.

– Rank and file MDs are aware of programs/goals and can articulate organization’s approach to quality/efficiency.

3. Measurable outcomes that demonstrate efficiencies.

– Regular evaluation and reporting back to MDs/hospitals

4. Incentives/remedies to modify practice patterns and ensure compliance.

– Meaningful financial incentives/penalties (payer or internal)

5. Significant investment in infrastructure

– Support development/management of clinical programs

6. Common electronic medical record

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Components of a Clinically Integrated Network

Clinically Integrated Network

Common Practice

Standards and

ProtocolsPrograms to

monitor & control

utilization and ensure quality

Measurable outcomes that demonstrate efficiencies

Incentives & remedies to modify practice patterns & ensure compliance.

Significant investment in infrastructure

Common electronic medical record

The elements that define a

clinically integrated

network are the same elements

that will improve performance and

patient care quality

The elements that define a

clinically integrated

network are the same elements

that will improve performance and

patient care quality

9

Agenda





10

Evolving Reimbursement and Care Models

Fee-for-Service

P4P (“Lite”)

P4P (Robust)

Case Rates

Sub-Capitation

Full Capitation

PA

YM

EN

T M

ET

HO

DO

LO

DY

STAGE OF EVOLUTION

Solo MD Practices

Multi-Specialty Group Practices

Integrated Delivery System

Clinic Model Group Practices

Non-MD Clinicians

Registries

EMR

Disease Management

Team-Based Care

Closed System

Evolutio

n of S

upporting S

ystem

s

Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System

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Components Of P4P Programs

Incentives

Targets

Measurement

Payment or withhold needs to be large enough to provide incentive to physicians

– Withhold pool can be significant at practice or system level but at the provider level the amount of money can be very small

– Timing of withhold settlement impacts the link between the performance and return

Efficiency targets – goal of lowering costs– Prescribing generic medication– Ordering radiology exams that impact clinical decisions

Quality goals – goal of improving health outcomes – Targeted diseases (e.g. diabetes, cardiovascular disease)

Process goals – goal of changing status quo behaviors or instituting new processes to improve quality of care

– Electronic prescribing– Testing targets (e.g. number of eligible patients w/ mammogram)

Data source: claims vs. clinical record vs. patient reports Adjustments: severity, socioeconomic status Group vs. individual physicians

Component Choices

12

Major Target Areas in Partners P4P Contracting (Phase 1)

Hospitals

Hospital use (and type)

Radiology

Computer order entry

JCAHO cardiac quality measures

Physicians

Hospital use

Pharmacy

Radiology

Electronic record adoption

Diabetes/Asthma/ Chlamydia screening


13

Community PCP EMR Adoption

Community PCP EMR Adoption TrendE

0%

20%

40%

60%

80%

100%

2003 2004 2005 2006 2007

Live Implementing

Data as of December 31, 2007.


14

New Major Target Areas in Partners P4P Contracting (Phase 2)

Hospitals Hospital use (and type) Radiology► Safe medication administration

systems (e.g., eMAR, smart pumps)

JCAHO cardiac quality measures

► NSQIP/IHI► Patient experience of care

(HCAHPS)► End of life care

Physicians Hospital use Pharmacy Radiology► Electronic record effective use

(electronic prescribing, problem list accuracy)

► Diabetes outcomes (LDL, BP, HbA1c)

► Patient experience of care► End of life care► Shared decision making► High risk patient identification

and referrals

The contract goals are becoming more meaningful – and that is only possible because of the progress with EMR and

other systems achieved thus far.Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System

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2009 Summary Of BWPO Physician P4P Programs

Quality: • Programs that identify and support physicians in management of patients with targeted diseases

• Case Management for patients at risk for readmission

• Pharmacy management for targeted patients

Process:• E-Prescribing Training

• Advanced directive education

• Distribution of patient education materials

P4P Goal BWPO Medical Management Program

Efficiency: • Prescribe generics and lower cost brand drugs where appropriate

• Order appropriate imaging tests when necessary for diagnosis management

• Encourage appropriate “site of care” for individual patients

Overview

• Pharmacy• Radiology• Inpatient

• DM• HTN• CVD

• E-RX• End of Life• Shared Decision

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Annual cost differential: prescribing a generic drug can provide a patient (and the system) over a four fold cost savings to the patient and a ten fold overall cost savings

$540

$120

$468

$0

$0

$200

$400

$600

$800

$1,000

$1,200

Lexapro citalopram

co-pay additional cost

Efficiency: Pharmacy Example

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Problem: What happens when we don’t get it right the first time?

Mrs. Jones is a 50 y.o. female.

Newly diagnosed with depression.

Rx - Lexapro

Cost Barrier $45 co-pay

Access Barrier Prior Auth Required

Prescribed by Psychiatrist

No Fill

Rx – citalopram $10

copay

Back to PCP Fill

Goal: To influence MDs behavior so they “write right” the first time.


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BWPO PRIMARY CARE PRESCRIBING POLICY

“It is the policy of Brigham and Women’s Primary Care to first prescribe a generic or over the counter (OTC) drug if available. When there are no Generic or OTC drugs available, or if there is a documented generic/OTC failure, physicians will work with patients to find an appropriate alternative.”

Pharmacy: BWPO Primary Care Prescribing Policy


19

Physician Education Approach: Adult Therapeutic Grid

Therapeutic ClassFormulary Costs* Formular Costs* Formulary Costs*

SSRI's fluoxetine $12 Zoloft $79

citalopram $38 Paxil CR $85

paroxetine $68 Prozac Weekly $104

Proton Pump Inhibitors omeprazole $68 Protonix $128 Aciphex $137

Prilosec OTC $18 Nexium $140Prevacid $137

NSAIDs ibuprofen $9 diclofenac $25 Naprelan $124

indomethacin $9 etodolac $34 Mobic $120

naproxen $9 nabumetone $61

piroxicam $9

sulindac $14

COX IIs Celebrex $90

Third Line

*Costs based upon average cost of a 30 days supply for all dosages, unless otherwise indicated. AWP/MAC pricing

First Line Second Line


Physician Education− Target a sub-set of most frequently prescribed drug classes. − Clinical review of each class to support Therapeutic Effectiveness (PCHI Outpatient

Drug Management Committee).− Identify lower cost brand and generic alternatives.− Develop and disseminate PCHI Therapeutic Grid with supporting Prescriber and

Patient Education.

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40 y.o. female with dyspepsia

PCP enters

Rx - Nexium

LMR identifies Nexium as

“red” No

Rx

FillRx –

omeprazole

Select from Alternatives


Support providers at time of prescribing, guiding them to most efficient and cost effective Rx for specific patient based on their insurance or lack thereof.

Point of Care: Optimal Approach achieved through use of EMR

Point of Care Supports Efficient Prescribing and Promotes Quality Care Through Real Time Decision Support


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% Generic - By PCP (Example Of A Report For One BWPO Practice)

73.33% 75.17% 76.43%

84.46%

71.37%

80.00% 81.76% 82.56% 82.78%84.96%

83.92%78.41% 83.91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13

PCP % generic Avg. BWPO PCP % generic

• Average BWPO % Generic is 81.76% v. Practice average of 78.41%• Patients who pay generic vs brand co-pays save an avg. of $420/year• Studies show that high drug costs adversely impact medication adherence


• Pharmacy claims data Jan 08 – Jun 08

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BWPO Pharmacy: Use Of Generic Drugs Has Steadily Risen

54.00%

56.00%

58.00%

60.00%

62.00%

64.00%

66.00%

68.00%

70.00%

72.00%

74.00%

Q106 Q206 Q306 Q406 Q107 Q207 Q307 Q407 Q108 Q208 Q308 Q408

% Generic

BWPO pharmacy trends, q106-q408% generic prescriptions written


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20%

54%

78%

36%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

LDL < 100 A1c < 9 BP < 130/80 All 3

Opportunities For Improvement In Getting Patients To Target

Source: Matrix (CDR+Claims) as of 12/5/08Missing Data counted as “not at target”

% of BWPO P4P Patients with diabetes at target for LDL, A1C*, BP, and all three

Quality: Diabetes Example

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45% 46% 47% 47%50% 51%

54% 54% 55% 55% 56% 56%60% 62%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pra

ctice A

Pra

ctice B

Pra

ctice C

Pra

ctice D

Pra

ctice E

Pra

ctice F

Pra

ctice G

Pra

ctice H

Pra

ctice I

Pra

ctice J

Pra

ctice K

Pra

ctice L

Pra

ctice M

Pra

ctice N

Quality: Variation In LDL Target Achieved By Practices

Percent of patients with CVE or diabetes at LDL target

Source: Matrix (CDR+Claims) as of 12/5/08LDL Compliant: LDL Drawn in 2008 with value less than 100


27

BWPO PCP “Action” Reports: Inform Physicians about Patients and Offers Provider Support for Follow-Up


28

There is no “one size fits all” solution…but using electronic communication with linkage to EMR improves efficiencies.

Results from the PCP “Action” Reports PCPs Returned the Reports Reports alone are not an effective tool for enrollment of patients in programs

external to PCP office Only 5% of eligible patients were signed up for LDL titration program via

report Further education on protocol followed by direct email outreach with

communication of eligible patients along with LDL titration protocol to PCPs resulted in much higher interest in enrollment.

Preliminary results reveal approx 60% enrollment rate

Next Steps List Management Software

Electronic communication Links from the reports directly into the patients medical record Use electronic survey communication to capture physician follow-up

orders


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E-prescribing Adoption

E-Prescribing improves physician efficiency and patient quality

− With ‘favorites” it typically only takes a few clicks to prescribe and renew prescriptions

− Prescriptions are accurate and clear, no more deciphering physician handwriting

− System can provide real time decision support: system can warn of drug/drug interactions, allergies listed in patient record, lower cost alternatives

BWPO developed a program that customized the medication module for each practice and trained physicians on how to efficiently use the system

Key elements

− Leadership buy in

− Engage “super-user”

− Customize medication module – set up favorites and short cuts

− Customize training – presentations, one-on-one

Process: E-Prescribing

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E-prescribing: preset “favorites” help physicians quickly prescribe meds they use most often


31

E-prescribing: Real Time Decision Support


32

BWPO E-prescribing Performance improving

36%

91%

70%69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PCP Spec

% E

-RX

Q407 Q408

2009 Target: 75%

Percent of physicians using e-prescribing


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Some shortcomings of P4P

Focus on achieving process metrics, not always on outcomes

– E.g., testing targets focus on getting the test done, not the resultsProcess vs. Outcomes

Too much vs. too little

Work to the target and not beyond If threshold set too high, some MDs may not see hope of payment

Lack of “fairness”

Majority of targets linked to PCP engagement; very few current goals tied to specialist engagement

Providers at risk for things they can’t control– Poor patient adherence

– Varying severity of illness

Confusion Different payors have their own programs, with their own targets Not all patients included, but physician practice doesn’t change by payer Often difficult to measure with existing data resources

Problem Description

34

Agenda





35

CMS: PQRI and Value Based Purchasing

CMS Physician Quality Reporting Initiative

– Current model is “bonus” for “reporting” on selected quality metrics and demonstration of E prescribing

– Physician participants to date have experienced many challenges and few have received anticipated payments

– Anticipate will become “required” for payment, not “bonus” going forward

CMS Issue Paper December 2008 with plans to transition from FFS to “Value-Based Purchasing”

− Acknowledging that fee for service NOT effective for ensuring quality and efficiency

− Goal of providing right care for every person every time

− Promote practice of evidence based medicine (msmt, financial incentives, public reporting)

− Decrease fragmentation and duplication of care (episodes of care, smoother transitions)

− Effective management of chronic diseases (focus on prevention, preventable admissions, advanced care planning, end of life care)

− Accelerate adoption of HIT

− Empower consumers to make value based health care choices

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Take risk on things you can control

Engage physicians in the process

Leverage EMR technology –

– Creates efficiencies in engaging physicians at point of care

– Provides more comprehensive information about individual patients

– Deploys clinical decision support

– Captures information for measurement and reporting

Aim for concordance of measures across health plans

Be proactive in designing systems

– Approach may vary by measure

– Understand your organization’s strengths and weaknesses

Measuring the impact of a program can be a challenge

– Process vs. outcome

– Quality vs. efficiency

Modify programs as you learn more

Some Conclusions from P4P

37

A recap

P4P Contracts have begun to engage some physicians around addressing quality and efficiency…but financial risk is minimal and affects primarily primary care physicians and not specialists.

The intense expansion of medical knowledge and technology and the accompanying rising costs demand changes in the traditional models of individual providers caring for individual patients under a FFS system and support more team based care with alternative payment models which support quality and efficiency of care delivery.

The electronic medical record is a critical tool in providing physicians with the best available information about an individual patient and is key to improving efficiency and effectiveness of care. Physicians need to adopt the use of EMRs and will need to be trained in effective use.

Data and reporting are essential for measurement of performance; showing variation vs. one’s peers is an effective means to engage physicians.

Patients will need to become more engaged in their health care management and decision making with increased transparency.

pay for performance: experiences within an integrated delivery system

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